Dr Gerard Panting answers questions on prescribing off licence, and diagnosing and prescribing over the internet



Q A patient recently presented me with information from the internet and suggested that I follow the treatment regimen set out. It consisted of a herbal remedy and treatment with a vasodilator which, although licensed in this country, is not licensed for that indication. She said I was obliged to prescribe the treatment she wanted. Can she be right?

A Only if failure to provide the treatment she requested would amount to negligence. In other words, she would have to be able to prove that she suffered harm because you did not give her what she wanted.

Unfortunately, not all the information available on the internet is as authoritative as some people might like to believe. Whether it is a traditional medicine or a herbal remedy, the criteria for prescribing a drug must be exactly the same, ensuring it is the right drug for the right patient in the right dose and that all necessary monitoring is in place.

Ensuring that it is the right drug includes considering the possibility of any interactions and, particularly where herbal remedies are concerned, information may be sparse. While doctors will not wish to dismiss patientsÍ suggestions out of hand, it would clearly make any defence very difficult if the doctor had prescribed medication that he or she knew nothing about.

Many drugs are used outside their licensed indications and provided there is a sound evidence base for using the vasodilator to treat this condition, that there are no comparative or absolute contraindications to its use, and that the necessary monitoring is in place, the fact that it is unlicensed for that use is not a bar to prescribing it.

Q A couple of colleagues plan to set up an internet advisory service primarily, but not exclusively, for ex-patriots. It seems very straightforward but are there potential pitfalls here?

A In some ways, providing advice over the telephone, a videolink or the internet is no different from providing advice face to face. The bottom line is that the doctor must be in a position to make a sound clinical judgment before giving any advice to the patient.

The difficulty in these situations is that the amount of information the doctor receives is limited by the nature of the communication. Even on a videolink, it is difficult to pick up non-verbal cues but the vast majority of remote consultations take place over the telephone or the internet, which make diagnosis even harder.

Even when there are no obvious communication problems in telephone conversations, it may prove difficult to obtain all the information that is required. For instance, a patient suffering with chest pain may want reassurance that it is only indigestion and it may be tempting for the doctor to go along with the idea, especially if the patient has had similar symptoms before. However, if the doctor is not in a position to make a sound clinical judgment, securing his or her defence will be an uphill struggle.

Over the internet, the situation is further complicated by potential time delays and perhaps the limited keyboard skills of one or both correspondents.

In all these situations, the final safety net is to ensure that patients whose condition cannot be diagnosed are referred to a more local doctor for a face to face consultation.

Q One of my patients has obtained Viagra over the internet. He is very cagey about his source but can doctors just prescribe like this?

A Quite a lot of drugs are readily available over the internet, the practices of some suppliers being more straightforward than others. Certainly the GMC has taken a tough line on doctors prescribing drugs like Viagra over the internet if they have failed to make sufficient enquiry about the patientÍs condition and to ensure that it is an appropriate drug to prescribe for them.

Guidelines in Practice, October 2002, Volume 5(10)
© 2002 MGP Ltd
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